APEXOGENESIS & APEXIFICATION

Presented By : Vipul D. Giratkar

Final Year - II

Contents

• Introduction

• Treatment Modalities of pulpal pathology

• Apexogenesis – Defination

Rationale

Goals

Indications

Contraindications

Procedure

Medicaments

• Apexification – Defination

Objectives

Indications

Contraindications

Procedure

Medicaments

• Difference between Apexogenesis & Apexification

• Conclusion

• Reference

Introduction - Pulp The dental pulp is the part in the centre of the tooth made

up of living connective tissues and cells called

odontoblasts

The dental pulp is a part of dental pulp

complex(Endodontium)

The vitality of the dental pulp complex , both during

healthy and after injury depends on pulp cell activity and

the signaling process that regulates the cell’s behaviour.

Functions – Nutritive

Sensory

Protective

Formative

Treatment ModalitiesPULP TREATMENT

MODALITIES

Vital pulp therapy

1. Protective base.

2. Indirect Pulp capping.

3. Direct Pulp capping.

4. Pulpotomy.

5. Apexogenesis.

6. Regeneration.

Nonvital Pulp Therapy :

1. Pulpectomy

2. Apexification

3. Root filling

Young Permanent teeth are those recently

erupted teeth in which normal apical

physiological root closure has not occurred.

Normal physiological root closure of

permanent teeth may take 2-3 year after

eruption

Young permanent teeth are in developmental

stage in children, from 6 years of age until mid

teens .

Human tooth with immature apex : is a

developing organ.

The proliferation and differentiation of various

cells are activated especially in the apical

region of young tooth to make it complete.

Apexogenesis• Definition – It is defined as the treatment of a vital pulp

by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale• Maintenance of integrity of the radicular pulp

tissue to allow continued root growth.

• Root end development occurs in a tooth with a

normal pulp and minimal inflammation

• Pulp of immature teeth has significant reparative

potential

• Pulp revascularisation and repair occurs more

efficiently in tooth with an open apex

• Poor long term prognosis of an endodontically

treated immature teeth

Relatively thin dentin in obturated canals of

immature roots and open apex are prone to fracture

Goals of Apexogenesis :

1. Sustaining a viable Hertwig’s sheath to allow continued

development of root length for a favourable crown : root ratio

2. Maintaining pulp vitality to help maturation of root.

3. Promoting root-end closure to create a natural apical

constriction.

4. Generating a dentinal bridge at the site of pupotomy.

(a sign that the pulp has maintained it’s vitality).

Indications1. Indicated for traumatized or pulpally involved vital

permanent tooth when root apex is incompletely formed.

2. No history of spontaneous pain.

3. No sensitivity on percussion.

4. No Hemorrhage.

5. Normal Radiographic appearance.

6. Traumatic Luxation.

Contraindications1. Evidence that radicular pulp has undergone degenerative

changes.

2. Tooth with unfavourable horizontal root fracture i.e. close to

gingival margin

3. Purulent drainage.

4. History of prolonged pain.

5. Necrotic debris in canal.

6. Periapical Radiolucency.

PROCEDURE

Remove all of carious tooth strucuture and open up the pulp chamber

Remove coronal pulp with excavators, care is taken to prevent damage to radicular pulp

Rinse all the residual debris and control hemorrhage by placement of a moist cotton pellet over the amputed pulp

Calcium hydroxide mixture is placed over the pulp stumps, followed by temporary restoration

Follow-up radiograph are taken periodically to check the root development

Once the root development is complete, the conventional root canal treatment is done.

`

Medicament

• Calcium Hydroxide

• Formocresol

• Glutaraldehyde

• MTA (Mineral Trioxide Aggregate)

• Zinc Oxide Eugenol Paste

• Iodoform Paste

Apexification• Definition : It is defined as a method to induce

development of the root apex of an immature pulpless

tooth by formation of osteocementum / bone like tissue.

( Cohen )

Objectives• To induce either closure of open apical third of root canal

or the formation of an apical calcific barrier against which

obturation can be achieved.

Indications• For young, immature, nonvital permanent tooth with

open apex

• Open apex

• Blunderbuss

canals

• Thin and fragile

canal walls

• Absolute dryness

of canal difficult to

achieve

Why apexificationpreferred over RCT

Contraindications

• Very short roots

• Vital Pulp

• Compromised Periodontium

Materials used• Zinc oxide Eugenol

• Metacresylacetate – campahorated

parachlorphenol

• Tricalcium Phosphate + β – tricalcium phosphate

• MTA (mineral trioxide aggregrate)

• Collagen calcium phosphate gel

• Calcium hydroxide

Procedure – Single Visit Preoperative asessment includes clinical evaluation of

colour, mobility , tenderness, and swelling

Periapical radiograph should be evaluated

When acute signs and symptoms are absent, instrumentation is recommended

Application of rubber dam following local anesthesia

Access is gained in the pulp chamber

Barbed broach is used to remove debris and necrotic pulp tissue along the canal

Irrigation is performed with saline

Working length is determined

Circumferential enlargement done by the file and irrigation is done with saline to remove infected dentin from the canal

walls

Canal dried with paper points

Calcium Hydroxide is used to fill 2mm short of the radiographic apex

Remaining of the canal filled with calcium hydroxide and saline

Barium sulfate added to radiopacity

Dry pledged of calcium hydroxide is then ejected into the pulp chamber and forced against the paste ahead of it

Place temporary Restoration

Second Visit

This is after 6 – 24 months

Tooth is re-entered and apexification is verified

It is complete when RCT is done.

Follow - Up

• Apical development is monitored by comparison of

preoperative and postoperative radiograph.

• 1. Formation of calcific bridge

• 2. Continued apical development

• 3. Absence of internal resorption or periapical

radiolucency

Use of calcium Hydroxide1. Alkaline pH

2. Bactericidal

3. Stimulate apical calcification

Reaction of periapical tissue to calcium hydroxide is

simillar to that of pulp tissue.

Calcium Hydroxide produces a multilayered sterile

necrosis permitting subsequent mineralization.

Serious Disadvantages

• Long treatment period usually takes 6 – 9 months and

may extend upto 21 months.

• Must be replaced at monthly intervals and removed some

months after placement before final obturation

• Multiple visits by the patient

• Possible recontamination may occur

• Weaken the root dentin and the risk of teeth fracture.

MTA as choice of material for Apexification

• Saves treatment time

• Can induce formation (regeneration ) of dentin, bone,

cementum and periodontal ligament

• Excellent biocompatibility and appropriate

mechanical properties.

• Excellent sealing ability

• Produces an artificial barrier, against which an

obturating material can be condensed

• Hardens (sets) in the presence of moisture

• More radiopaque than calcium hydroxide

• Vasocontrictive

Composition

• Tricalcium aluminate

• Tricalcium silicate

• Silicate oxide

• Tricalcium oxide

• Bismuth oxide

Types

Gray MTA White MTA

Contains tricalcium

aluminoferrite (ferrous oxide)

which is responsible for gray

disccoloration. So it causes

discoloration of teeth.

Therefore, it is not used for

anterior teeth.

Ferrous oxide is replaced by

magnesium oxide. So no tooth

discolouration.

Large particles Small particle with narrower

size distribution

Longer setting time Shorter setting time

Greater compressive strength Less compressive strength

Properties

• Biocompatible

• Sealing ability better than amalgam or ZOE

• Initial pH – 10.2 and set pH – 12.5

• Setting time – 4 hours

• Compressive strength – 70 Mpa

• Low Cytotoxicity ( it presents with minimal

inflammation of extended beyond the apex )

Comparative assessment of Apexification

using MTA and Calcium Hydroxide

Difference between Apexogenesis and Apexification

Apexogenesis Apexification

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued growth of the root and closure of the open apex

It is defined as a method to induce development of the root apex of an immature pulpless tooth by formation of osteocementum / bone like tissue. (Cohen)

It is physiological process of redevelopment in vital infected tooth

It is the method of inducing the regenerative potential in a non-vital tooth

Normal or pulp tissue with minimal inflammation is present : 1. Completely (Direct Pulp Capping)2. In the radicular portion (Pulpotomy)

Indicated in cases where there is no normal pulp tissue i.e., where the pulp has undergone irreversible pulpal necrosis.

Normal root end development takes place

Normal root development takes place rarely. Calcific barrier is formed clinically, on a radiograph or both

Conclusion• Apexogenesis and Apexification are two variants of

procedures performed.

• It is very important to use appropriate procedure at appropriate

age in presenting conditions.

• Ideal material suitable for the condition of the pulp should be

selected and used.

• Proper care should be taken following these procedures.

Reference

• Textbook of Pediatric Dentistry (3rd Edition) – By

Nikhil Marwah

• Textbook of Pedodontics (2nd Edition) – By Shobha

Tandon

• Internet sources